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[Reprinted from the Special Number on Gastric Diseases, Philadelphia. 
Medical Journal, February 3, 1900.] 


of Johns Hopkins Hospital. 

In a study of 150 consecutive cases of carcinoma of 
the stomach in the medical department of the Johns 
Hopkins Hospital, we have been very much interested 
in a group in which the disease was unsuspected dur- 
ing life. As Welch remarks, it is rare to find cancer of 
the stomach in an apparently healthy man dying of 
accident. The latent cases are most frequently met 
in old persons, in whom the symptoms may be 
very slight, or absent, or they are mistaken for the 
ordinary dyspeptic complaints of the aged. Even after 
•the most thorough examination it may not be possible 
to reach a diagnosis. In obscure cases, particularly 
with dyspepsia and emaciation, the possibility of latent 
carcinoma should be borne in mind. 

There are three groups of cases of latent carcinoma 
of the stomach : 

1. A very small one in general hospitals, a very large 
one in almshouses and asylums, comprising cases in 
which the symptoms are those of a gradual enfeeble 
ment without any indication of local disease — as Oliver 
Wendell Holmes puts it, in the " One Hoss Shay," " a 
general flavor of mild decay, but nothing local." 

2. Cases in which, with an absence of gastric symp- 
toms, the lesions of associated disease seem sufficient 
to account for the condition. In this group were 
4 of our cases. In 2 the diagnosis of nephritis was 
made; 1 had advanced pulmonary tuberculosis with 
pneumothorax, and the fourth showed profound ane- 
mia with multiple venous thrombi. The following is a 
summary of these cases: 

Casb I. — Diagnoria of nephritia, arterioacleroaia and pleuriay ; 
no gaatric aymptoma. 
No. 22. A. G., Hcspitfll Nos. 2454 and 3251, male, aged 61 
years, first admitted January 22, 1891, complaining of short- 

ness of breath. A history of dyspnea, for some years. He 
had frequent attacks at night, and any ordinary exertion 
was difficult. With this he has had frequent cough. He 
had little appetite and the bowels had been loose. 

Examination: Dyspnea, cyanosis, and edema. The ar- 
teries were very sclerotic. There was fluid in the left pleural 
cavity; over 600 cc. were withdrawn. The heart's action 
was rapid, with gallop rhythm; on January 20, 900 cc. 
were withdrawn from the left pleura, and the following dav 
a friction-rub was heard in the left axilla. There were al- 
bumin and tube casts in the urine. The dyspnea gradu- 
ally lessened, and by February 16 his condition was much 

The patient remained in the hospital until April 29 ; on 
discharge he was still slightly cyanotic, but the dyspnea 
had gone. There was slightly impaired resonance on the 
left side of the chest. There was nothing noteworthy about 
the abdomen. During his stay there were no gastric symp- 
toms and the general condition of the patient improved. 

Second admiasifin, May 19, 1891. three weeks later. He 
looked very ill, cyanosed, and with dyspnea and hiccough. 
The pulse was scarcely perceptible. On May 23, 260 cc. of 
fluid were withdrawn from the left pleural cavity. His con- 
dition remained much the same until death on June 5, 1891. 
There was no complaint of any gastric symptoms. The 
temperature was practically normal during both admissions. 
There was no loss of weight on the second admission, and 
the nephritis and arteriosclerosis seemed to account for the 
symptoms, and no stomach-symptoms were present to draw 
attention to that organ. 

Autopsy showed carcinoma of the stomach and esophagus, 
there being an elevated tumor-mass 7 by 2 cm.,which was halt 
in the stomach. The center was ulcerated. There was chronic 
diffuse nephritis, arteriosclerosis, aortic and mitral insuffi- 
ciency, ana chronic pericarditis. There was pleural exudate 
with a fibrinous pleurisy over an infarction in the right lung. 
There were no metastases. Thrombi were present in both 
sides of the heart and in the pulmonary artery. 

Cask II.— Oeneral edema ; albumin and granular and hyaline 

tube casts in urine, rapid emaciation ; vomiting at onset, 

but none during his stay in hospital; diagnosis of ntphritis. 

No. 73. T. C, Hospital No. 10,234, male, aged 61, admitted 

June 26, 1894, complaining of swelling of the legs. His 

family history was negative. He gave a history of an attack 

like the present 20 years ago, which lasted for 2 months. He 

then had both edema and dyspnea. In the last 5 years he 

had gradually lost over 40 pounds. His present illness began 

about 5 weeks before with persistent vomiting which lasted 

for one week. Swelling of the legs then appeared, and the 

vomiting stopped. He was able to keep at work until 4 





days before admission. His ajjpetite has been good, 
and the bowels regular. Examination showed marked 
emaciation and fairly general edema. There was slight dul- 
ness over the right base. The abdomen was distended, tym- 
panitic in the elevated and dull in the dependent portions, 
but it was held so tensely that attempts at palpation were not 
satisfactory. The urine was of dark color. Specific gravity 
1012, showed a faint trace of albumin and contained hyaline 
and granular casts. The temperature was slightly elevated. 
The edema increased and the patient died on July 4. 

Autopsy showed a large scirrhous cancer involving nearly 
the whole of the stomach, and extending to the esophagus. 
The stomach was adherent to all surrounding structures. 
The growth extended through to the peritoneum at places. 
There were secondary growths in the glands and liver. 

Case III. — Tuberculosis and pneumothorax, all the symptoms 
those of chronic consumption ; no slonuich symptoms. 

No. 71.— J. A., Hospital No. 10,050, male, aged 41 years, 
admitted June 7, 1894, complaining of pain in the chest and 
cough. His family history was tuberculous. He had been 
very healthy previously. His present illness dated back 
about six months, though for some time before he had been 
troubled with a cough. This became worse, he had sharp 
pain in the left chest and several attacks of hemoptysis. 
For five months he had diarrhea, with the passage of mucus 
and blood in the stools. He has not had any appetite. 
There has been much loss of flesh. There was no history of 
any stomach-symptoms. 

Examination showed great emaciation. There was club- 
bing of the fingers. There were marked signs on both sides 
of the thorax, both on percussion and auscultation. Pneu- 
mothorax was present on the left side. The abdomen looked 
natural, was nowhere tender and was negative on palpation. 
The temperature was only slightly elevated. The patient 
rapidly sank and died on June 11. 

Autopsy showed cancer of the lesser curvature of the 
stomach with secondary growths in the lymph-glands and 
liver. The mass measured 6 by 5 cm. It was soft and fun- 
goid in character. The pvlorus was free. There was tuber- 
culosis in both lungs and pneumothorax on the left side. 
Tuberculous ulceration of the large and small intestine was 
also found. 

Case IV. — Multiple thrombi of superficial cutaneous veins; pro- 
fotmd and progressive anemia; no gastric symptoms. 
No 64. G. N., Hospital No. 9131, male, aged 50, admitted 
January 31, 1894, complaining of weakness and pains in the 
arms and legs. His family and previous history were nor- 
mal. The present illness, which began four weeks before, he 
attributed to exposure, wet and cold. He had a chill fol- 

lowed by fever, which lasted some days. Pain then began 
in each leg and then in the arms. THese were sharp, made 
worse by movement and there was a great tenderness of the 
muscles on pressure. There was not any edema, but great 
weakness. The appetite was poor. The bowels were regular. 
Examination showed no marked general change, except 

pallor and sallowness. The thorax was normal. On exami- 
nation there was epigastric tenderness and marked resistance 
of the abdominal walls. Neither the spleen nor liver was 
enlarged. Many of the superficial veins of both the arms 
and Tegs were represented by firm hari cords. These 
thrombosed veins were somewhat sensitive. A i^ortion of 

one of these veins in the arm was removed. The thrombus 
was soft and could be squeezed out. Cultures made from it 
were negative. The chart shows the remarkable extent of 
the thrombosis : 

Blood— Hemoglobin 39%. 

Red corpuscles 2,300,000. 

White corpuscles 6,000. 

On February 10 edema appeared in the left leg. Very 
many of the superficial veins showed thrombosis. The left 
foot felt as warm as the right. On February 15 edema began 
in the right leg. The left femoral vein could be felt as a firm 

The anemia increased, the blood-count on February 16 
being : 

Hemcglobin 22 fo. 

Red corpuscles 1,716,000. 

White corpuscles 29,000. 

The differential count showed 89 % of polymorphonuclears. 
No nucleated red corpuscles were seen. 

The patient gradually sank and died on February 18, 1 894. 
His temperature was constantly somewhat elevated. There 
were no stomach-symptoms. 

Autopsy showed cnncer of the pylorus with secondary in- 
volvement of lymph-glands, gastrohepatic, anterior medias- 
tinal ^nd subclavicular, and the liver. The mass occupied 
the lesser curvature and did not involve the whole pylorus, 
so that the orifice was not narrowed. There were also multiple 
venous thrombi. 

This remarkable case excited very special interest, 
more particularly the unusual number of thrombi in 
the superficial veins, and their association virith great 
tenderness in the muscles. Though we spoke of the 
possibility of malignant disease, yet there was no posi- 
tive evidence obtained. He was not given a test-meal, 
as there were really no features whatever pointing to 
the stomach. 

3. Cases in which the metastases completely mask 
the primary disease. 

Case V. — Paraesthesia in feet ; symptoms of ataxia ; gradual 
paraplegia ; headache ; marked pain in neck ; development 
of a tumor in the right side of the pelvis ; no stomach symp- 
toms. Autopsy ; primary carcinoma of lesser curvatare of 
the stomach ; secondary masses in the abdominal glands, the 
right ilium and the femur. 

No 106. J. W., male, white. Hospital No. 14,944. Aged 
40 years. Admitted January 10, 1896, complaining of 
inability to walk and pain in the neck and legs. His history 


was negative and he had been healthy until his present 

Present illness began about 8 months before with peculiar 
sensations as of " pins and needles " in the feet. In about 
2 months the Aveakness in the legs had so increased that he 
was unable to walk. Sensation was almost absent in the 
feet. Headache and pains in the neck had been severe. 
There had not been any special stomach symptoms, although 
he had vomited occasionally. 

Examination showed emaciation and marked pallor. The 
abdomen was practically negative in the upper part. A mass 
was felt deeply in the right iliac fossa, wh'ch was palpable per 
rectum and involved the bony parts of the pelvis. Th«-re 
was great wasting of the legs with absence of the kneejerks. 
Blood examination showed hemoglobin 48% ; red corpus- 
cles, 2,432,000. 

The patient had severe pain which required large amounts 
of morphin. The tumor of the right pelvis increased in 
size. He lost ground in every way. In February he devel- 
oped marked mental symptoms with ideas of persecution, 
etc. Death followed on March 14, 1896. 

Autopsy showed primary carcinoma of the leaser curvature 
of the stomach. The stomach was of normal size and on 
the anterior wall in the region of the lesser curvature was 
an area of new growth 6 cm. in diameter. There was no 
ulceration. Histologically, the growth was a colloid carci- 
noma. There were secondary growths in the abdominal 
glands and in the right ilium and femur. Unfortunately, the 
spinal cord was not examined. 

Case VI. — Pains in the right arm and right side of neck, wUh 
wasting of the muscles of the right arm ; inequality of the 
pupils; development of nodular masses on the ribs ; diagnosis 
of cancer, but primary disease not suspedfd ; no gastrio 
symptoms. Autopsy showed cancer of lesser curvature of the 
stomach ; a nodular mass compressing the brarhial plexus ; 
metastases in tenth dorsal and first lumbar vertebrae. 

No. 124. G. K., Hospital No. 17,993, male, aged 39 years, 
admitted December 1, 1896, complaining of pain through 
the right shoulder and back, wi'h loss of sensation in the 
ri^ht forearm. His family-history was negative. He had 
had malaria every year for eight years past and pains in the 
shoulders and back, thought to be rheumatic. The most 
severe of these attacks was 18 months before, during which 
he spent two weeks in bed. Since then he has been very 
well and able to work. His occupation, an ironfitter, in- 
volved much heavy lifting. He never had any stomach or 
bowel trouble ; at times for many years he has had shortness 
of breath on exertion. 

The present illness began in August, 1896, with coughing 
and profuse expectoration. Pain soon came on in the right 

side, close to the shoulder, and was severe enough to make 
him §ive up work. The cough soon left him, but the pain 
remamed. It gradually went down the right arm. It was 
constant and described as boring in character. It was worse 
on movement. About one week before admission he noticed 
a loss of sensation in the forearm, and at the same time he 
lost power in the riglit arm, so that since then he has not 
been able to use it. The pain and weakness has also ex- 
tended to his back, so that he had difficulty in raising him- 
self up in bed. The legs were not affected. There was no 
history of any injury. There had not been any stomach- 
symptoms. The bowels had been constipated. He had lost 
nearly 20 pounds in weight and much strength. 

Examination showed fair nutrition. The patient remaim d 
usually on the left side, he seemed to suffer much pain and 
objected to changing his position or sitting up, on account of 
the pain it caused. There were prominences on the 4th, 5th, 
7th, 8th, and 12th ribs, not attached to the skin, but to the 
bones. They were very tender, had a slightly elastic, but 
not fluctuated feeling. Examination of the thorax was nega- 
tive. There was no dulness over the manubrium. The 
abdomen was flat, the muscles were held somewhat rigidly, 
so that palpation was difficult. There was marked wasting 
of the muscles of the right arm, and loss of power. There 
seemed to be some disturbance of sensation over the ulnar 
surface of the left arm, but the results we-e not constant. 
There was distinct inequality of the pupil, the left being 
larger. They both reacted to light and on convergence. 
Ophthalmoscopic examination was negative. The patient 
held himself very stiffly when asked to sit up, and the mobility 
of the head downward was much impaired. There was no 
pain on pressure over the spine. There was no general 
glandular enlargement. 

Blood— Hemoglobin 92%. 

Red corpuscles 5,752,000. 

White corpuscles 13,000. 

The patient had severe pain, and frequently required mor- 
phin hypodermically. He lost weight and strength. The 
masses on the ribs gradually increased in size, and became 
more tender. On December 26 it was noted that the abdo- 
men was very tense, and moderately distended. No other 
abdominal symptoms were present. The leukocytes increased 
and were 22,000 on the 20th. A differential count showed 85 % 
of polymorphonuclear. The patient generally sank, and 
died on December 30. During his stay he took nourishment 
fairly well. There was no complaint or sign of any gastric 

The case was regarded as probably one of primary 
neoplasm in the thorax with secondary deposits on the 


ribs and probably in the vertebrae. The absence of his- 
tory of any gastric trouble and of any signs during his 
stay in the hospital, did not call for special attention 
to the stomach, and no test-breakfast was given. The 
abdominal examination was always negative, except 
that the muscles were held tensely. As the patient was 
difficult of examination this did not perhaps arouse 
the attention it should have done. The true condition 
was not suspected. 

Autopsy showed cancer of the stomach. The lesser curva- 
ture was converted into a rigid mass over which the omen- 
tum was closely bound. The growth extended along the 
posterior wall. It did not involve the cardia or pylorus. On 
section all the coats were infiltrated. The mucous mem- 
brnne was smooth, white, and opaque. Near the pylorus was 
an i.icerat'^d area 3 by 3 cm. on the posterior wall. There 
were metastases in the lungs, bronchial, pericardial axillary 
and abdominal lymph-glands, ribs, skull, and vertebrae. 
There was compression of the bronchial plexus by a tumor- 
nodule. The vertebral metastases were in the first and tenth 
dorsal and first lumbar. 

Case VII. — Onset of illness with ascites; two months later aspira- 
tion of bloody fluid; recurrence of ascites ivith sivelling of 
the legs; drainage of peritoneum ; recognition of malignant 
disease of the stomach. Autopsy showed extensive cancer of 
the stomach. 

No. 141. A. H., male, Hospital No. 21,173, aged 59 years ; 
admitted November 9, 1897, complaining of * dropsy." His 
family history was negative. He had been a moderate 
drinker and denied syphilis. 

Present illness began four months previously with swelling 
of the abdomen. This increased gradually and at the end 
of two months he was tapped by his physician, who drew off* 
a large amount of bloody fluid. Soon after the abdomen 
began to enlarge again and this continued until the present 
admission. With this swelling of the legs came on. There 
had been some pain in the lower abdomen. His appetite 
had varied. He had occasional vomiting of mucus but no 
blood. The bowels had been irregular. There had been 
great frequency of micturition. • 

Examination showed emaciation but not cachexia. The 
thorax was negative. The abdomen was distended symmetri- 
cally. Movable dulness and fluctuation were obtained. The 
liver-dulness began at the fifth rib in the right nipple line 
and only extended a distance of 4 cm. Its edge could not 
be felt. There was edema of the legs, genitalia and lower 


The case was suggestive in some ways of cirrhosis of 
the liver, although the history of bloody fluid being 
obtained on previous tapping pointed to malignant 
growth. The absence of any stomach-symptoms seemed 
against a primary growth there. The patient required 
tapping and it was thought best to do this by an ex- 
ploratory exploration. 

Operation. — On the abdominal cavity being opened a bloody 
turoid fluid was obtained. A mass was found in the stomaen 
and secondary deposits over the peritoneum. The fluid 
showed numerous red corpuscles and leukocytes. There 
were also large cells many times the size of a leukocj'te, 
some of which contained more than one nucleus. No signs 
of karyokinesis were seen. Certain groups of cells were 
found which were very suggestive of masses of cancer-cells. 
After the operation a firm mass was to be felt in the left 
hypochondrium. In the right hypochondrium several nod- 
ules were felt. The patient was much easier after the opera- 
tion, but died suddenly on December 5, 1897. 

Aviopsy showed colloid carcinoma of the stomach along 
the lesser curvature from the cardia to the pylorus. The 
pylorus was converted into a dense ring and the growth ex- 
tended for a short distance into the duodenum. The esoph- 
agus was invaded but the cardiac orifice was not narrowed. 
The omentum and peritoneum were involved. The stomach 
was adherent to tne liver, spleen and diaphragm. The 
growth ex ended through the diaphragm to the pleura. 

In reviewing this interesting series of cases, and par- 
ticularly in the study of the autopsy records, one is 
astonished to notice how extensive and widespread the 
disease may be with practically no symptoms. In three 
of the cases a very large part of the stomach was in- 
volved, in two the cardiac orifice, and in two the pylorus. 
In one instance the growth involved the esophagus, 
and in one to a slight extent the duodenum. In three 
instances there was ulceration, and in five metastases 
were present. 

no. ')iO 

i ■ 


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